Virus is constant challenge at long term care facilities

For many Americans, it’s become a daily routine. Turn on the TV, scroll through the internet or open up a newspaper and digest the never-ending and rising statistics of the Coronavirus, or COVID-19. What started out as a few cases at the beginning of the year has exploded into a true national crisis. As of July, the United States has reached the grim milestone of four million cases and more than 140,000 deaths. Some experts are citing the easing of restrictions during the Memorial Day weekend as cause for the dramatic spike in cases and deaths. Indeed, in May, COVID-19 deaths were being viewed within the context of deaths in the Vietnam War. Only two months later, that context is moot. 

Viewed nationally, the pandemic is truly scary, but when broken down by state, one sees the deadly effects of the virus disproportionally spread, with more populace states in the east, west and south being hit the hardest. While other factors are at play – such as policy, politics and public attitudes – the virus has mainly thrived in more densely-packed feeding grounds. Thus, when one looks at any color-coded map of the United States, most Midwest states are shaded much lighter. 

Within Minnesota, the color coding, according to Centers for Disease Control statistics, is broken down by county, and shows cases generally spread across the state, with counties having larger urban areas being highlighted with darker shades of red. When looking at COVID-related deaths, though, the counties in and around the Twin Cities are swathed in ominous dark purple hues, in sharp contrast to the rest of the state that’s sprinkled with varying degrees of light, benign gray. In northeast Minnesota, St. Louis County has the highest percentage of cases and deaths. Carlton, Itasca and Koochiching. Lake and Cook counties, by contrast, barely register a blip.

One statistic that has made the news in Minnesota is the number of cases and deaths among Long-Term Care (LTC) facilities (a term used for higher populated facilities – including nursing homes, assisted-living, memory care and group homes) in comparison to the general public. According to the Minnesota Department of Health, as of July, out of the 1,561 COVID-related deaths in the state, 1,198 have occurred in LTC or assisted living facilities.  In June, MDH reported that more than 850 LTC facilities have or have had at least one known case of COVID-19, with the vast majority of these located in and around the Twin Cities. St. Louis County has confirmed cases in three LTC facilities, two in Duluth and one in Meadowlands. Adjacent counties have reported similar or fewer numbers, but overall, within a month, that number has increased.

In April, Centers for Medicare and Medicaid and the CDC started requiring consistent reporting by states in cases and deaths in nursing homes. Based on the reporting, Minnesota has 49.7/1,000 COVID positive cases in LTC facilities compared to a national average of 62/1,000 cases – which ranks Minnesota 26th among states. For COVID deaths, Minnesota has 12.1/1,000 COVID deaths in LTC facilities with a national average of 27.5/1,000 deaths – putting Minnesota 29th among states. Also, if death occurs in a hospital setting, the death is attributed to the resident’s LTC facility – other states do not report it this way, though.

While Minnesota is, statistically speaking, in the middle of the road of cases/deaths in LTC facilities, and the percentage is far lower than private residences, the actual hard numbers compared to overall cases and deaths in the state has raised eyebrows. The reason why isn’t as simple as accounting for age.

“Initially, Minnesota’s numbers of deaths reported were higher than most other states but that was because of two reasons:  First, we included a broader scope of residents in our death count in all congregate settings, which include assisted living, group homes and nursing homes; other states just counted nursing home deaths so our number was inflated in comparison,” said Patti Cullen, president/CEO of Care Providers of Minnesota, a non-profit state affiliate for the American Health Care Association/National Center for Assisted Living. “Secondly, we also counted deaths where COVID-19 contributed to the death whether or not it was the leading cause; other states did not. For example, a resident on hospice at the end of life was found post-mortem to have had COVID-19 – that death was counted as well.”

Another point Cullen made is that while nationally only 54.1 percent of nursing homes have infection control surveys, 100 percent of nursing homes in Minnesota have these surveys.

In short, more information leads to more worry, but also more understanding and more action, according to State Rep. Jennifer Schultz (DFL-Duluth). The 7A representative said she has been very concerned with the number of cases and deaths in long-term care facilities in Minnesota and across the country, suggesting the biggest mistake was not having a coordinated federal response. 

“Instead, states are competing for PPE, drugs and medical equipment to respond to the crisis,” said Schultz. “States have been reluctant to issue mandates for LTC facilities. Only seven states mandate testing in nursing homes. Many providers of LTC facilities are not following guidelines and/or are not able to follow guidelines, because they lack the resources to acquire PPE or have limited room and staff availability. This is contributing to cases and deaths. States may need to issue more mandates and help find the funds and resources needed by LTC providers. But providers need to be held accountable as well – they have a responsibility to provide a safe environment for residents. Our current situation is not acceptable — we need to be doing more and we need federal assistance to do it.”

Schultz said that for the past four months she and her state senate counterpart, Erik Simonson, have been working with LTC facility advocates, like AARP, Elder Justice, Legal Aid, Elder Voices and the Alzheimer’s Association, as well as state agencies and the governor’s office to provide resources and funding to respond to the pandemic in LTC facilities. 

“We have drafted legislation mandating infection control, testing of residents, staff and guests, and implementing various consumer protections to be effective before the assisted living licensure goes into effect in 2021, which will give protections from arbitrary lease and service terminations and electronic monitoring placement.”

In May, Gov. Tim Walz and MDH announced a five-point “battle plan” to limit the spread of COVID-19 in LTC facilities. In the months leading up to that announcement, state officials had been working with long-term care providers to help them implement and maintain strict infection control measures to help reduce the risk of introduction and spread of COVID-19 in facilities.  At a news conference on July 21, Walz announced that while residents of LTC facilities still make up a majority of COVID-19 deaths in Minnesota, data is showing that efforts to identify and contain the spread of COVID-19 in various congregate care settings have been successful. Facilities with both large and small outbreaks have successfully stopped the spread of the virus. Of the total 1,165 outbreak facilities, 714 or 61% have had 1-2 cases to date. Of these, 538 or 75% have had no COVID-19 cases for 28 days. As for the 95 facilities with larger outbreaks of 20 or more cases, 51 or 54% percent have been free of COVID-19 cases for 28 days.

“With an aggressive multi-pronged strategy, this battle plan is helping ensure Minnesota’s long-term care facilities are more resilient and better prepared to contain the spread of COVID-19,” said Walz. “We’ve made progress, but there’s still more work to do. Together with our partners in congregate care settings, we must continue to take action to protect our most vulnerable Minnesotans as this pandemic continues.”

Dave Uselman, executive director, Bayshore Residence & Rehabilitation Center in Duluth, said he appreciates the support from the many government agencies with staffing, additional PPE, reimbursement and increased testing as his facility and others try to safely open back up for their residents and their loved ones. But he’s also proud of the way his staff have adapted to the constant changes and challenges during the pandemic, ensuring the center stays on the positive side of the statistics.

“The fact that we are still COVID-19 free is a testament to the degree of professionalism and care in our staff,” said Uselman. “They have always been willing to put the residents first, even when we have to wear hot uncomfortable PPE and get prodded in our noses for the many rounds of testing we have done.  Our staff have proven themselves to be heroes and have done a fabulous job keeping the residents safe, preparing for when an outbreak hit and connecting the residents with friends and family as often as possible during this trying time that’s been anything but routine.” 

Minnesota’s five point plan 

Among the elements of Minnesota’s five-point plan that have been successfully implemented include:

• Developed testing criteria and a process for facilities to request testing services, making it possible to expand testing for residents and workers in long-term care facilities.

• Implemented a nurse triage line to provide test results and information on COVID-19 and streamlined the billing process for using the state’s testing partnership to provide testing support and troubleshooting to clear barriers faster.

• Developed a system for prioritizing and disbursing personal protective equipment (PPE) to facilities, including an emergency supply and response system, to ensure these materials are available when needed.

• Utilized a scheduling software system to connect facilities with staffing needs to available staff, as well as developed triggers and a notification system for when a facility needs additional staffing. In June, 112 shifts were filled through this system, representing 36 percent of available shifts. There are more than 1,100 qualified healthcare professionals signed up in the database.

• Leveraged partnerships at all levels, including state and federal agencies, as well as long-term care associations and regional healthcare coalitions to improve long-term care testing, staffing, PPE distribution, and patient surge capacity and discharge.